Doctors, scientists, politicians, and civil servants have been criticised by a major UK government inquiry into the handling of the crisis surrounding bovine spongiform encephalopathy (BSE).
The 16 volume BSE inquiry, published last week, reported a catalogue of errors but is reluctant to apportion blame. The inquiry exposed flaws in the way that the government seeks scientific advice and communicates risk to the public.
Lord Phillips of Worth Matravers, the inquiry chairman, set the tone: “Much of the inquiry has been taken up with examining this question [Was BSE correctly handled?]. The processes of government have been subjected to public scrutiny, which I believe has been without precedent. We have concluded that, in general, our system of public administration has emerged with credit from the part of the BSE story that we have examined.
“Sound policy decisions were taken, both with a view to eradicating the animal disease and with a view to protecting humans against what was believed to be a remote risk of transmission.”
The subtext of the inquiry report, however, tells a different story. It pointed out shortcomings in what was done and mentions unacceptable delays in the bureaucratic process and poor communication between ministries. The former Conservative government is said to have been “preoccupied with preventing an alarmist over-reaction to BSE because it believed the risk was remote.”
But the inquiry found that the government did not lie to the public, although its campaign of reassurance was described as a mistake. A key message to emerge from the report is that public reassurance on the basis of insufficient evidence is ill advised, and a policy based on openness and admitting ignorance is preferable.
The £27m ($38m) inquiry officially started on 12 January 1998 and was due to report in March of this year. It was non-statutory and did not have legal powers to require individuals to supply evidence or attend. The terms of reference were “to establish and review the history of the emergence and identification of BSE and variant CJD in the United Kingdom, and of the action taken in response to it up to 20 March 1996.”
Over 80 people in the United Kingdom have died, or are dying, from variant Creutzfeldt-Jakob disease (vCJD). Farmers have received hundreds of millions of pounds in compensation for the slaughter of over 170000 cattle. The report endorsed the view that BSE and vCJD are the same disease but pointed out that BSE is different from scrapie, a disease that affects sheep and was thought to have crossed the species barrier to cattle in the form of BSE.
The inquiry team claimed that, although the first case of BSE was officially reported in 1985, the first cattle were infected in the 1970s. If true, this raises the possibility of a high number of deaths from vCJD that have gone unnoticed. A recent study suggested, however, that the number of missed deaths is likely to be low (BMJ 2000;320:145-7).
On whether there was a government cover-up about BSE, Lord Phillips said at a press conference in London last week: “There was an initial embargo within the Ministry of Agriculture, Fisheries and Food on publishing information about BSE. This lasted about six months. After this there was no concealment of information. There was, however, a failure to give the public a balanced picture about risk.
The public was repeatedly reassured that it was safe to eat beef without always being told that this was because the potentially dangerous bits had been cut out. The public was not told that some might have been infected before this precaution was introduced. A false impression was conveyed that BSE posed no risk to humans.”
Sir Donald Acheson, chief medical officer from 1983 to 1991, was criticised for playing down the risk of transmitting BSE to humans after a cat had been diagnosed with the disease. A scientific committee, the Southwood Working Party, which was also criticised in the report, recommended that offal was safe for adults but not for babies.
Sir Donald's response to that recommendation was deemed unsatisfactory by the inquiry team. His successor, Sir Kenneth Calman, did not escape criticism either. The inquiry found that he too should not have made statements that played down the risk posed by BSE.
A formal government response to the Phillips inquiry has been promised. Immediate measures introduced include a compensation package for patients and relatives, and improved care packages for patients.
The BSE Inquiry is available from the Stationery Office, price £27.50 (general inquiries, tel 0870 6005522). The report is also available at www.bseinquiry.gov.uk
Key findings of the BSE inquiry
BSE has caused a harrowing fatal disease for humans. The link between BSE and vCJD is well established, although the mode of transmission remains unclear
The BSE epidemic developed because of the recycling of animal protein in ruminant feed
The measures introduced by the government to address the hazard were sensible but were often ill timed or inadequate
Risk communication was poor
The government's scientific advisory committees reached decisions too slowly and unsatisfactorily
Bureaucratic processes resulted in unacceptable delays in putting policy into practice
The government did not lie to the public, but its policy of reassurance was a mistake
Figure.
PRESS ASSOCIATION
Donald Acheson, 1990: British beef can be eaten safely by everyone”